Provider Demographics
NPI:1508050824
Name:SOUDERS, PAMELA LYNN (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:LYNN
Last Name:SOUDERS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MRS
Other - First Name:PAMELA
Other - Middle Name:LYNN
Other - Last Name:SEALOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-1700
Mailing Address - Fax:414-955-0072
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-1700
Practice Address - Fax:414-955-0072
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.006724363LF0000X
WI3343363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1508050824Medicaid
WI1508050824Medicaid